Gordon Lodge Rest Home

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We continued to find significant shortfalls in the quality of care and support provided. There continued to be areas of the building which were not clean. Though people did now have access to soap and towels to wash their hands. Medicines remained poorly managed. People continued to be placed at risk, potential risks to people’s health and welfare were not always assessed and there continued to be a lack of guidance for staff. There was no analysis of accidents and incidents to identify patterns and trends. There were no longer alway enough staff to meet people’s needs. Staff understood their responsibility to report safeguarding concerns but action had not always been taken to keep people safe.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People didn’t always feel encouraged and supported to raise concerns.

We asked the provider to show us the systems they had in operation to learn from medicines errors. They told us they did not have a system in place and would implement one following our assessment.

The provider had not acted since our last assessment to audit accidents and incidents to look for patterns and trends. Safeguarding incidents were recorded in people’s care records and not as incidents. Accidents continued to be looked at individually but there was no oversight of patterns, such as who was falling or when. People continued to be at risk as action had not been taken to learn from accidents and incidents to prevent them happening again. There had been no improvement since our last assessment, action had not been taken to record, investigate and learn from medicines administration errors. For example, one person’s pain relief patch had been administered a day late, leaving them at risk of increased pain. Action had not been taken to investigate how this occurred, and put plans in place to ensure it did not occur again, leaving people at risk of not receiving their medicines as prescribed to treat their medical needs.

People were not always supported to move safely between services. One person’s relative told us that their loved one had been waiting to access a health professional for several weeks. They had spoken to the staff about their concerns but were not happy with their response, they had not chased the referral.

Staff told us they still did not receive detailed information about people before they moved into the service. A staff member told us they continued to receive 'basic information before the person comes in’ and ‘within a day or 2 a more detailed basic care plan’. Medical professionals had agreed with one person that they would not be admitted to hospital unless their condition met specific criteria. The person took medication to reduce their blood clotting which increased their risk of bleeding. A member of the management team told us there were no plans in place to obtain medical treatment for the person if they sustained an injury which caused them to bleed. There was a risk the person would become unwell because pathways had not been agreed to obtain advice and treatment if they sustained an injury.

The service had received feedback from health professionals to express concerns staff had not always supported and been available when they visited.

Action had not been taken since our last assessment to ensure staff had all the information they needed to provide people’s care and support when they moved into the service. Staff did not have care plans and risk assessments providing basic guidance before people moved in, to keep them safe. We asked the provider to send us the pre admission assessments and care plans for 2 people who had moved in since our last assessment. They sent us 2 assessments but no care plans. It was unclear how accurate the assessments were. For example, one was dated 2 days before the person moved in but stated, ‘has been having all their meals in their room. Staff to encourage them to have meals in the dining room with other people’. It also stated the person was at high risk of bruising but not why this was or if any action was to be taken if they person sustained an injury. The other assessment stated the person required 2 staff to support them with personal care but no guidance was provided about how staff were to support the person. There was a continued risk people would not receive safe, consistent care and treatment in the way they preferred.

Not all safeguarding risks had been identified. People told us they did not always feel safe in their own room when one person had been walking around the service. This had been raised as a safeguarding concern by a healthcare professional but not by the service.

Staff told us they were aware of occasions when a person's privacy had not been maintained and another person had come into their room. They had taken action by locking the person's door when providing personal care. However, no other action had been taken to support the person to feel safe at other times. Staff told us the risk had been removed as the other person had now left the service. We asked a member of the leadership team what action had been taken to protect the person’s privacy and dignity and support them to feel safe and relaxed in their home. They told us no action had been taken and they felt as the safeguarding concern had been closed no further action was required. We asked if they had spoken to the person and tried to understand how they may feel about an uninvited visitor in their bedroom. They told us they had not. One staff member told us, “I don’t feel I always have someone to speak to about concerns for people’s needs.”

People were safely supported. We observed staff talking with people, reassuring them and treating them kindly.

The provider had not always taken effective action to protect the people from potential harm and abuse. There were no effective systems in place to raise, report and act upon safeguarding concerns consistently.

People expressed they were generally happy with their care and told us they felt safe. However, one person told us that they had some anxieties around how staff were managing their health condition.

Staff told us they did not to have time to read people’s care plans and continued to rely on their experience to meet people’s needs. One staff member told us the care plan files contained information which was no longer required and they struggled to find the correct information to share with health care professionals. A person’s records stated they were to take a strong pain killer before they received treatment, the medicine was in stock but had not been administered for several days. We asked a member of the leadership team why the person had not received their medicine, they told us it had been stopped by health care professionals and confirmed they had not updated the person’s care plan or risk assessment. There was a risk people would be given medicines they were no longer prescribed.

We observed staff supporting people to move around the service and eat safely. We observed people being involved in making day to day decisions.

There were no effective systems in place to make sure guidance for staff was relevant and accurate to reduce risks to people. Guidance for staff about the support people required had not been updated when their needs changed. One person was no longer prescribed medicine to help them sleep. However, guidance for staff around their mental health, cognition and medicines continued to state the person took the medicine. The risks of people falling were not well managed. One person, at high risk of falls, had a mat placed outside their bedroom to inform staff they were walking around. This had not been affective. They had fallen once in July and 3 times in August in or near their bedroom. The care plan stated the person stepped over the mat and an accident report recorded staff thought the person had ‘jumped over’ the mat. No action had been taken to look at alternative ways to reduce the risk of the person falling and they continued to be at risk of injury. Guidance to staff about risks related to catheters had improved, such as the signs they may be blocked. However, there continued to be a lack of guidance about how to care for the catheter, including how to keep it clean and when to change the bag. People continued to be at risk of developing an infection. Guidance for staff about each person’s diabetes had improved but more improvements were required. For example, no guidance had been provided about the foods and drinks to offer people.

People using the service told us they felt safe and did not share any concerns, one person told us “I know where I am when I’m here, I know I can get help”.

The management team had not recognised risks within the environment. A member of the leadership team told us the light on the stairs to the cellar, used to store cleaning materials and other items was not working and an electrician had been called the week before to repair it. They had not taken action to keep people safe when the door to the cellar was open. People were able to go near the open cellar door without supervision placing them at risk of falling down the stairs.

One person had a mat in their room to let staff know when they were walking around. A member of the leadership team told us there were 2 mats one on top of the other as the one on the top did not work and the one underneath was not none slip. We observed the mat on the top was not flush to the floor and caused a trip hazard. Staff had not recognised this hazard and to person remained at risk of tripping. We observed one person had an ‘overlay’ pressure relieving mattress on their bed. This was laying directly on to the bed base. We asked a member of the leadership team what the mattress was overlaying. They told us it was not an overlay mattress. We pointed out the mattress had the manufacturers label stated it was an overlay mattress. The staff member told us it was not overlaying anything and they had not noticed this before and would arrange for it to be changed. The person was at risk of developing skin damage because they had not been provided with an adequately supportive mattress.

At our last assessment we found the environment had not been designed to support people living with dementia move safely around the building without support. The provider had not acted and no changes had been made. The provider’s environmental risk assessment had not been reviewed and updated since our last assessment and continued not to be specific to the building, grounds and equipment used at the service. The cellar was not included and risks to people and staff had not been identified and mitigated. The one change the provider had made was to change the lock on the rear gate to make sure the garden used by people was secure.

In a recent survey one relative had commented, “Staff can be sometimes very busy and rushed’. There had been a number of unwitnessed falls where staff had not been present, resulting in injuries including broken bones.

Staff responsible for administering medicines told us they were often interrupted during the medicines round to complete other tasks and advise other staff. They told us this led to medicines mistakes. Other staff told us there were not always enough staff on duty and people had to wait for their care. They told us, “It’s too busy to read care plans”, “We haven’t got time for the residents” and “I go home sometimes feeling bad because they haven’t had what they deserve”. Staff told us there were inconsistencies in staff deployment, for example sometimes there were 4 care staff on duty and on other occasions there were 3. They told us 4 staff were needed to provide all the support people needed. They also told us care staff were taken off the floor to complete domestic duties. This had occurred on the day of our site visit. Staff told us they covered vacant shifts to support colleagues and felt people would suffer if they did not. They told us this impacted negatively on their wellbeing and personal life. They also told us they would like to spend more time with people not providing personal care and “I don’t have enough time to chat with people”. Staff told us the registered manager did not support them on the floor when they were busy. They said the deputy manager and head of care supported them occasionally but not consistently when they needed support. There were staff vacancies and other staff were working their notice, including member of the leadership team. We asked the provider what plans they had in operation recruit to the vacancies. They responded, "I am currently recruiting for a domestic/ laundry to cover a member of staff who is retiring. Also additional care staff to eliminate the use of agency staff covering holidays & absence. I have identified a candidate for the manager's position." They did not have a robust plan in place to ensure vacancies were covered.

Staff deployment at lunchtime had not been planned so people could be supported to eat without interruption or receive the support they wanted. One person in the dining room dropped some food and became distressed, there were no staff in the room to support them. They had to wait for the staff member supporting a person in the lounge to leave the person they were supporting to help them. This happened several times to support different people in the dining room. Several people chose to eat in their bedrooms. No staff were responsible for checking people, to make sure they had what they needed and were safe. We observed staff did not have time to spend with people unless they were supporting them and rushed from one task to another. An activities coordinator had been employed since our last assessment and we observed people engaged in games and activities they enjoyed.

The provider did not have a robust process in place to plan staff deployment to meet people’s needs. Their Recruitment Retention and Deployment of Staff Strategies stated: ‘We regularly evaluate the number of residents and their care needs (e.g., medical, personal, and emotional care). We create a detailed staffing plan based on residents’ physical conditions, such as mobility, cognitive decline, and other specific care requirements using a dependency assessment tool. This process used a generic system to calculate how many hours of one to one care people required each day, but did not allow for people’s individual needs or the time required to support people between personal care. We analysed staff deployment records, these showed staffing levels were inconsistent and reflected what staff told us. For example, there were 6 days in the 3 weeks before our assessment when there were only 3 care staff on duty, on other days there were 4 or 5. Records showed there were often less staff between 16:30 and 20:30 to support people with their evening meal and get ready for bed. The leadership team were not recorded on the rota and staff told us they did not know when the registered manager would be on site. Three people required support at mealtimes, action had not been taken to ensure the people received their meals without interruption and other people received the support they needed. Two staff were deployed at night and 3 people who required 2 staff to help they move or reposition themselves in bed. When staff were supporting these people no staff were available to support the remaining 20 people. Staff had not been supported to complete training in relation to catheter and stoma care. Again some staff have not completed training updates in relation to day to day care, including health and safety or moving and handling. Seven staff had not completed training in infection control and we found infection control risks at the service. This left people at risk of harm.

People were living in an environment which was not clean and using equipment which posed an infection risk. Some people's bedrooms had not been cleaned sufficiently and there was an odour of urine.

The leadership team had not identified infection risks. We asked how they cleaned the fabric covered arm chairs in the people’s bedrooms when they were soiled. They told us, they used upholstery cleaner. When asked, they told us they had not considered the need to clean the foam padding to reduce the risk of odour and infection. There were no strategies in place to disinfect the chairs. We asked a member of the leadership team what strategies were in place to check mattresses were clean, they told us they were wiped over when the beds were changed. We asked if the covers were removed regularly to check they continued to be impervious to fluids and the core of the mattress was not soiled. They told us the covers had never been removed to check the cleanliness of the mattress.

The service and equipment continued to dirty and an infection risk. Equipment and furniture around the service including vanity units and dining tables continued to have chipped and damaged surfaces which were difficult to clean. Toilet frames had been secured to the floor to reduce the risk of people falling, however several were rusty making them difficult to clean and disinfect. Some people preferred to have a bath and used a bath hoist to get in and out of the bath. The bath and bath hoist were dirty. A member of the leadership team told us the staining was rust and wiped it with a wet wipe, some of the staining came off on the wipe and they confirmed the bath hoist was dirty. Clinical waste bins were available for the disposal of soiled incontinence products and other items. We observed some items had not been double bagged to reduce the risk of infections spreading. We observed areas of the service were dirty when we arrived on site and these areas continued to be dirty when we left.

The provider’s infection prevention and control (IPC) policy reflected the Health and Social Care Act 2008: code of practice on the prevention and control of infections, however, the policy was not consistently followed. For example, an IPC lead with the appropriate knowledge and skills had not been appointed to oversee the implementation of organisational policies, set and challenge standards of cleanliness and ensure there was a programme for ongoing staff training and competency assessment. The provider completed a monthly IPC audit. In August 2024 they recorded no concerns regarding staffs’ completion of infection control training, despite 7 staff not have completed up to date IPC training and 6 staff not having up to date hand hygiene training. In June 2024 they noted not all staff had short nails, no action was recorded and there was no record of checks being made to ensure staff had taken action to comply with the providers requirements. In June no concerns were noted about dirty or rusty shower or bath chairs. In July it was noted 2 toilet surrounds had been removed, the August audit stated ‘replace shower chair’. No date for this action was recorded and we saw rusty toilet frames and bath and shower chairs remained. Furniture which was not in a good state of repair, such as dining tables and vanity units had not been identified as IPC risks. Following our last assessment the provider had implemented cleaning records and staff ticked to confirm they had cleaned specific areas of the service each day. This system had not been effective in improving the cleanliness of the service.

People did not raise any concerns related to their medicines.

We spoke to a staff member about the disposal of unwanted liquid medicines. They told us if a person did not want the dispensed dose of liquid medicine they poured in back into the medicines bottle. There was a risk of medicines becoming contaminated when this practice was completed.

Effective action had not been taken to improve medicines management at the service. Some people were prescribed medicine to treat or prevent blood clots. Risks that people may bleed or bruise more than normal because their blood would not clot as easily had not been assessed. This left people at risk of not receiving the treatment they needed to keep them safe and well. Some people were prescribed medicines ‘when required’, including to manage constipation, relieve breathing difficulties or pain relief. The provider had not taken effective action since our last assessment to provide staff with detailed guidance, including when medicines should be administered, the maximum dose to administer in a 24 hour period and the action to take if they were not effective. There was a continued risk people would not receive their medicines when they needed them or would receive too much medicine. Records showed one person had not received medicine to reduce the amount of acid their stomach made for 9 days because it was out of stock. There had been an 8 day delay in a member of the leadership team being informed of this and it was not in stock on the day of our site visit. This left the person at risk of pain and discomfort from indigestion, heartburn or acid reflux, or not receiving treatment for a stomach ulcer. Safe processes were not in operation to dispose of some medicines. There had been no improvement in medicine records, they continued to be inaccurate and placed people at risk of not receiving medicines as prescribed.